Provider Demographics
NPI:1548232770
Name:SENICA, BRYANT M (OD)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:M
Last Name:SENICA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 CAPRI BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5661
Mailing Address - Country:US
Mailing Address - Phone:928-855-9477
Mailing Address - Fax:928-855-1799
Practice Address - Street 1:40 CAPRI BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5661
Practice Address - Country:US
Practice Address - Phone:928-855-9477
Practice Address - Fax:928-855-1799
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0903020OtherBCBS
AZ316499Medicaid
AZAZ0903020OtherBCBS
AZ316499Medicaid
AZU56994Medicare UPIN